Healthcare Provider Details

I. General information

NPI: 1356963839
Provider Name (Legal Business Name): SUMMIT BEHAVIORAL HEALTH OF AZ, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2020
Last Update Date: 05/07/2020
Certification Date: 05/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1989 WILLOW LAKE RD UNIT 100-105
PRESCOTT AZ
86301-4885
US

IV. Provider business mailing address

8183 E FLORENTINE RD
PRESCOTT VALLEY AZ
86314-8481
US

V. Phone/Fax

Practice location:
  • Phone: 928-756-0694
  • Fax: 928-708-9620
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN T ISENBERG
Title or Position: CEO
Credential:
Phone: 928-710-7021